An Episcopal (Anglican) Chaplain in the Saint Luke's Health System of Kansas City, reflecting on work and faith and life. NOTA BENE: my opinions are my own and do not represent the Episcopal Church or the Saint Luke's Health System.

Thursday, August 27, 2009

Now, back to where Jon Stewart and Betsy McCaughey were wrong (all right, I’m more concerned with how Betsy McCaughey was wrong, but she wasn’t alone).

The second issue that Betsy McCaughey is concerned about in HR 3200 is inclusion of advance care planning consultations in physician quality measures.In the interview Jon Stewart didn’t really address this concern.Unfortunately, early on he had latched on to her idiosyncratic interpretation of the language in the section of the resolution under discussion and didn’t really go into detail that much himself.I wish he’d addressed this in detail.

The relevant passage from HR 3200 is as follows:

‘‘(3) PHYSICIAN’S QUALITY REPORTING INITIATIVE.—

‘‘(A) IN GENERAL.—For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life sustaining treatment.

Now, this includes the language that so concerns Ms. McCaughey; specifically, “Such measures shall measure both the creation of and adherence to orders for life sustaining treatment.”Her interpretation of this is that it creates incentive for the physician to encourage the patient or perhaps the patient’s family to follow the guidelines expressed in the advance directive or POLST document, even if the patient’s wishes have changed.She comes to this interpretation because quality measures are expected to have an impact on physician reimbursement under Medicare.

Like so many misunderstandings, this one has some truth involved in it.In fact quality measures are expected to have an impact on physician reimbursement under Medicare.However, a couple of the premises for her alarm are incorrect.First and foremost, not only are there no such quality measures defined in the proposed bill, any measures that do get defined will not be defined by the Federal Government, whether in Congress or in the Center for Medicare/Medicaid Services (CMS).Any such measures under this resolution would be “adopted or endorsed by a consensus-based organization.”Now, it might not be clear what would constitute a “consensus-based organization,” but it certainly isn’t either a group of politicians or of CMS bureaucrats.That is, of course, if such measures are developed at all, since the paragraph notes that they will only be developed “if appropriate.”

Moreover, the concern that any measures would “measure both the creation and adherence to orders for life sustaining treatment,” misunderstands both the context within the resolution and in our current health care system.The emphasis of Section 1233 has been protection of the patient’s right to make decisions about end-of-life care, and expect them to be followed.One of the reasons that this is a concern is resistance of physicians to even acknowledge that the patient has come to an end-of-life situation in the first place.The point of discussing such measures as hospice and palliative care is a recognition that there remain limits to what medical care can provide; or, as I periodically remind folks, the mortality rate of being human is 100%.For all of us, there will come a time when there won’t be anything more therapeutic care can offer, whether we’re prepared to change our goals or not.

While there are patients who want to pursue all possibilities no matter what, the greater difficulties are physicians who refuse to acknowledge their limits.There are many physicians who see their purpose as defeating disease, regardless of the consequences for the patient – or, for that matter, of the patient’s wishes.Perhaps there aren’t quite as many as there used to be.Medical education and residency programs have changed, especially in respecting the autonomy of the patient (and, after all, we are always fighting the last war).However, the difficulties remain.We still see too many patients suffering through difficult and uncomfortable treatments that are known at the time to offer little.We still see too many patients living with pain because physicians know too little about palliative care and adequate pain management.We still see too many patients whose physical existences are extended but their lives not enhanced because physicians consider neither the limitations of medicine nor the wishes of their patients.

In that light, the importance of measuring adherence to advanced care plans is clear – that is, the importance of measuring how consistently physicians adhere to the patients’ wishes.When the patient is able to speak, this is not an issue.The principle of autonomy is so pervasive in health care that it is a rare physician who will not do what the patient wants, even if the physician thinks the care futile (after all, there’s a good reason we speak of this autonomy as one of the principles of the “Georgetown Mantra”.If the patient’s wishes have changed, the current wishes will be followed.

Rather, the concern arises when the patient is not able to speak.In that instance, we wouldn’t be measuring the patient’s adherence, because the patient is no longer making decisions.Rather, we would be measuring the physician’s adherence with the patient’s wishes as we know them.Would it be possible that the patient’s wishes had changed?It’s not impossible, but on what basis would we make such a presumption?It is possible that the patient’s family might have a different perspective?Perhaps; but how would it be right for us to support even family in contravening the patient’s wishes?It is worth noting that best practice is not to ask family members what their wishes are, but what they know of the patient’s wishes.

Still, let us imagine that such measures were developed by the “consensus-based organization,” including measures of how well a doctor adheres to the patient’s wishes.That does not mean that they would be adopted.Here is the next paragraph:

‘‘(B) PROPOSED SET OF MEASURES.—The Secretary shall publish in the Federal Register proposed quality measures on end of life care and advanced care planning that the Secretary determines are described in subparagraph (A) and would be appropriate for eligible professionals to use to submit data to the Secretary. The Secretary shall provide for a period of public comment on such set of measures before finalizing such proposed measures.’’

Thus, these measures, developed “by a consensus-based organization, if appropriate,” would be publicized and subject to public review before being finalized, much less utilized.It’s hard to develop much anxiety about a set of measures subject to so much review and, indeed, so tentative.

That also raises the last point on which Ms. McCaughey seems confused (and, really, Jon Steward was no better).Ms. McCaughey and many others have spoken of HR 3200 as if it were the law under consideration.In fact, that’s far from certain.There are at least two other proposals in the House of Representatives.There are also two proposals under discussion in the Senate.So, before we see an actual law, there will be to be three sessions of negotiation: one in the House, one in the Senate, and one in Conference.Really, there will be four, because there won’t be a law until the form agreed in Conference is agreed once again in both Houses.Ms. McCaughey might well think these provisions are bad ideas.However, things are far enough from resolution that such intense fear-mongering seems more than a bit of a stretch.

Unless, of course, what you really want is to disrupt the process.

One of my favorite Nasruddin stories is of the day a neighbor wanted to borrow his clothesline.He answered, “I can’t lend it out.It’s in use.”

“What are you using it for,” the neighbor asked.

“I’m using it to dry flour.”

“You can’t use a clothesline to dry flour!” said the neighbor.“That’s just an excuse!”

“How well it works is none of your business.And it’s a good enough reason if I don’t really want to lend the clothesline anyway.”

So, this discussion of quality measures to induce physicians to violate or inappropriately influence the wishes of patients doesn’t make sense.It doesn’t meet standards of logic, based on reading the wording of the resolution, much less on the problems in health care.Of course, she could simply misunderstand what she’s reading; after all, Jon Stewart appears to have himself.But then, she is an attorney, with a Ph.D. in constitutional history.She certainly believes she understands.So, I have to wonder, just how is it that she gets so much so wrong?

I’ll be getting back to Betsy McCaughey, but something more interesting and immediate popped up.

One topic I often find myself teaching is basic information on ethics in health care. One point I address is the difference between “ethics” and “morals.” We use the words almost interchangeably, but there are differences. For the most part, “morals” is about principles – these things are good, and these things are bad. Ethics, on the other hand, are about process. Those who take this position might even speak of the “calculus of ethics.” Acting as if it’s an equation, if one has the right process, plug in any set of premises and you’ll get a result. There is, of course, a limitation to that idea: if your premises are poor, so will your result be; or, as my best beloved says, “The ethical enterprise is morally bankrupt.” A good logical process can be made useless if the concepts brought to bear are unsound.

Which is, I suppose, what I should have expected when, in his latest opinion piece at the Washington Post, Charles Krauthammer started off with, “Let's see if we can have a reasoned discussion about end-of-life counseling.” (If you don't want to join on line, you can also find it here.) Not that I didn’t agree with his first statement, “We might start by asking Sarah Palin to leave the room. I've got nothing against her…. But there are no "death panels" in the Democratic health-care bills, and to say that there are is to debase the debate.”

Unfortunately, after that promising beginning, the piece rapidly goes down hill. It goes downhill first and foremost because of his apparent lack of faith in those of his first profession. Krauthammer presents in this piece a remarkably poor opinion of physicians, and this is surprising inasmuch as he is himself a Harvard-trained and board-certified psychiatrist. Even though he has long since left medical practice himself, one might still expect some respect; but it just isn’t there.

The topic in question (as, coincidentally for Betsy McCaughey – or, perhaps not) is the content of the consultations on advance care planning for which reimbursement would be permitted in HR 3200. Krauthammer begins with his caveat: “To offer government reimbursement to any doctor who gives end-of-life counseling -- whether or not the patient asked for it -- is to create an incentive for such a chat.” Unfortunately, he then steps away from reasoned discussion.

What do you think such a chat would be like? Do you think the doctor will go on and on about the fantastic new million-dollar high-tech gizmo that can prolong the patient's otherwise hopeless condition for another six months? Or do you think he's going to talk about -- as the bill specifically spells out -- hospice care and palliative care and other ways of letting go of life?

I find this an interesting question for one physician to raise about another. I also find it contrary to my empirical experience in almost 30 years as a chaplain, and contrary to those studies that have been done about care at the end of life. I've never known a physician who wasn't prepared to talk about new treatments or devices. This utterly misses the problem that we see in practice: that physicians have historically been too slow to honor the patient’s wishes for comfort measures, and not too eager. It is axiomatic in the profession that, while a patient might qualify for hospice support when there is nothing more to be gained from therapeutic care and a prognosis of less than six months, by the time physicians acknowledge that there is nothing more to gain the patient lives less than six months – often enough less than six days.

However, this is clearly Krauthammer’s concern; for this is how he ends his piece:

So why get Medicare to pay the doctor to do the counseling? Because we know that if this white-coated authority whose chosen vocation is curing and healing is the one opening your mind to hospice and palliative care, we’ve nudged you ever so slightly toward letting go. It’s not an outrage. It’s surely not a death panel. But it is subtle pressure applied by society through your doctor. And when you include it in a health care reform whose major objective is to bend the cost curve downward, you have to be a fool or a knave to deny that it’s intended to gently point you in a certain direction, toward the corner of the sick room where stands a ghostly figure, scythe in hand, offering release.

Well, Dr. Krauthammer, perhaps it’s not a death panel, because only one physician at a time is involved. So, perhaps you would call them “death deputies?” And with that suggestion, and in light of the bedside experience of so many, I wonder who is calling whom “a fool or a knave.”

This is all, in his mind, justified by a second questionable premise: that a patient’s right to make known wishes for care at the end of life, and to expect those wishes to be followed, is unimportant, or at least less important than the wishes of others. He highlights this with a false dichotomy.

Then consider the actual efficacy of a living will. When you are old, infirm andlying in the ICU with pseudomonas pneumonia and deciding whether to (a) gothrough the long antibiotic treatment or (b) allow what used to be called “theold man’s friend” to take you away, the doctor will ask you at that time whatyou want for yourself — no matter what piece of paper you signed five yearsago.

You are told constantly how very important it is to write your living will yearsin advance. But the relevant question is what you desire at the end — whenfacing death — not what you felt sometime in the past when you were hale andhearty.

Of course your doctor will ask your preferences for care when you are dying in the ICU – as long as you are able to speak for yourself. However, that isn’t the purpose of advance care planning, and he knows it. The point of advance care planning is when you can’t speak for yourself. It is to allow those who love you and those who care for you to act as you would wish when you can’t express your wishes.

But, this is not his agenda. “I’ve never taken [my own living will] terribly seriously because unless I’m comatose or demented, they’re going to ask me at the time whether or not I want to be resuscitated if I go into cardiac arrest. The paper I signed years ago will mean nothing.” Well, yes, if he can speak. And if he can’t?

And if I’m totally out of it, my family will decide, with little or no reference to my living will. Why? I’ll give you an example. When my father was dying, my mother and brother and I had to decide how much treatment to pursue. What was a better way to ascertain my father’s wishes: What he checked off on a form one fine summer’s day years before being stricken; or what we, who had known him intimately for decades, thought he would want? The answer is obvious.

So, is Dr. Krauthammer saying he violated, or was prepared to violate his father’s wishes? Those were certainly set down “before being stricken;” but the reason was that they might be reasoned decisions, in line with his principles and values, and not simply emotional reactions. So, did Dr. Krauthammer violate his father’s wishes? Perhaps not; for if they had indeed been communicating over those decades, there’s no reason to think his father changed his mind. On the other hand, it’s also common enough in my experience for families to provide their own subtle pressure, and sometimes not so subtle: “We can’t bear to lose you. Please keep fighting, just for us. We know you’re in pain. We hear that there’s nothing more medicine can do; but please keep fighting, just for us.” I would have to ask the good doctor, the good Harvard-trained, board-certified psychiatrist, how he was certain that he had not projected his own wishes onto his father, if he did not follow his father’s wishes expressed when he could do so calmly and rationally? Really, just whose wishes was he following in that moment that he admits was emotionally charged (as it certainly should be)?

So, given a choice between rational planning and ongoing family communication, and last minute emotional reactions, perhaps swayed by his own wishes, Dr. Krauthammer would choose the latter as serving the patient’s best interest. Well, that raises another questionable premise of the patient’s best interest. While that must be decided in each individual case, there are principles that guide professionals in that process. In this case, both because it is physicians who are faced with these decisions and because Dr. Krauthammer is himself a physician, we might look to the Code of Ethics of the American Medical Association (AMA). Specifically, we can look to “Opinion 2.20 – Withholding or Withdrawing Life-Sustaining Medical Treatment,” which includes this:

If the patient receiving life-sustaining treatment is incompetent, a surrogate decision maker should be identified. Without an advance directive that designates a proxy, the patient’s family should become the surrogate decision maker… In making a substituted judgment, decision makers may consider the patient’s advance directive (if any); the patient’s values about life and the way it should be lived; and the patient’s attitudes towards sickness, suffering, medical procedures, and death.

(1) Patients and physicians should make use of advisory as well as statutory documents. Advisory documents aim to accurately represent a patient’s wishes and are legally binding under law….

(5) Health care facilities should honor, and physicians use, a range of orders on the Doctor’s Order Sheet to indicate patient wishes regarding avoidable treatments that might otherwise be given on an emergency basis or by a covering physician with less knowledge of the patient’s wishes.

The point of all this is that the physician is enjoined and the family encouraged to act according to the patient’s wishes, even when the patient is past expressing them. Thus, while “what we, who had known [the patient] intimately for decades, thought he would want,” may be accurate, the physician at the bedside is called to help clarify between what the patient has expressed and what the family might want for their own needs; and then as best possible to follow the patient’s wishes. To do otherwise, as Dr. Krauthammer implies, could violate the AMA’s Code of Ethics and principles of patient-centered practice.

So, in fact this is far from a “reasoned discussion about end-of-life counseling.” In fact, it’s not really that different than Sarah Palin’s statement; for what is the difference that makes a difference between a “death panel” and a “death deputy?” No, this is another expression of fear – perhaps of Dr. Krauthammer’s own fear – made less obvious by a calm tone of voice. It may sound rational, but that doesn’t make it so; anymore than a good ethical process can make a good decision out of unsound premises. I will grant that in his history Dr. Krauthammer has experience both of deciding in his father’s case and of his own life-threatening illness. However, much of his “reasoning” seems in fact to be his own projection of his own concerns.

I’m all for a reasoned discussion of end-of-life counseling, and of end-of-life care. However, expressing distrust of the physicians at the bedside; lack of awareness of how these problems are experienced in practice; a choice the emotional decisions of the family in crisis over the patient’s decisions made when calm and thoughtful; and an invitation to violate medical ethics don’t make for reasoned discussion. They simply make for more and prettier fear-mongering – as if the rumor whispered could be less troublesome than when shouted, or a mindless placard more rational than a mindless cry.

Tuesday, August 25, 2009

If you didn’t see Jon Stewart’s interview with her (you can watch the segments here), or haven’t heard about her otherwise, Betsy McCaughey is a past Lieutenant Governor of New York and a participant over the years of a variety of think tanks at the Conservative end of the spectrum. She has a law degree and a Ph.D. in Constitutional History from Columbia. She has expressed a particular interest in health care issues. Certainly, she has her credentials.

She is also the person who has claimed that the best known of the three health care reform bills being sorted out in the House of Representatives , HR 3200, is, as she said on the Daily Show, “dangerous to seniors.” With that claim, she’s been getting a lot of attention from the Conservative media, and from some Republican legislators (I haven’t seen any of the “Blue Dog” Democrats quoting her; if they have I’m open to correction). Interestingly, she also got a lot of attention in the 1990’s when she also opposed the Clinton health reform proposals, which she also considered dangerous (albeit not on the same grounds). While she has not made the claim, those who have spoken of “Death Panels” have pointed to her work.

I’m not surprised at the attention. She’s attractive, works to be pleasant, and, as I’ve said, she has her credentials. Which is why she surprises me. Jon Stewart was wrong about some items in the specific section of HR 3200, but so was she. And with all her credentials, and her claim to have read the entire bill carefully, that’s more disturbing.

First, anyone can read the bill on line. I haven’t read all 1017 pages. However, in her interview with Stewart, Ms. McCaughey was kind enough to cite pages where she found difficulty. She even suggested that context was important. She pointed out that the statements describing the conversation between patient and physician was on one page, but that the impact of that conversation on the doctor’s quality rating is on another. And was there a hint in her voice that this separation was intended to hide that information, to deceive? Perhaps not; perhaps it was only to suggest Stewart hadn’t read enough. In any case, the pages aren’t that far apart, and when you read them you discover that they’re part of the same numbered section of the bill.

So, I have looked at the portion of the resolution at issue. It is Section 1233, Advance Care Planning Consultation, and it runs from pages 424 to 434 of the resolution. It does include discussion of the consultation, and it does speak about quality measures. However, beyond that there’s almost nothing accurate about what Dr. McCaughey is saying.

First, she speaks of the bill as describing the contents of the consultation, areas that the doctor must address. It does, but for only in terms quite general and quite familiar:

Such consultation shall include the following: ‘‘(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.‘‘(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses. ‘‘(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.‘‘(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965).‘‘(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

Now, there’s absolutely nothing new in any of these. They simply require the physician to point out to the patient resources such as Health Care Treatment Directives, Durable Powers of Attorney for Health Care, and resources for understanding and completing them. These have been in the landscape since the Patient Self-Determination Act was passed in 1991. Where is the set of categories Ms. McCaughey discerns?

They’re not in the next subsection.

‘‘(F)(i) Subject to clause (ii), an explanation of orders regarding lifesustaining treatment or similar orders, which shall include—

‘‘(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;‘‘(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and‘‘(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

However, while they’re not here, this is interesting because of what it points to: orders for life sustaining treatment – or perhaps I should write, Orders for Life Sustaining Treatment. For, this section is addressing a new movement in discussing care of patients at the end of life, and ensuring that they are cared for in accordance with their wishes. The efforts to develop Physician Orders for Life Sustaining Treatment (POLST) documents began in Oregon. (I've written about them here.) They are in fact the result of such a consultation, but with an added benefit. Like a health care treatment directive, it provides a form on which a patient’s wishes about care at the end of life can be recorded. Like a Durable Power of Attorney for Health Care, it provides an opportunity to name an agent, the person who speaks for the patient when the patient can’t speak. However, it comes out of a consultation with a physician, and it comes with an additional nuance: it comes as a set of physician orders to carry out the patient’s wishes, orders that by mutual agreement and enabled by the state are recognized by all health care institutions in the patient’s area, whether the particular doctor is credentialed or not. Thus, if a patient has a POLST document and is taken to an emergency room, the POLST document will be recognized as a valid order set whether the completing physician is on staff there or not.

And for a POLST document there are specific criteria. These are described in the bill, and are probably the source of the “list of criteria” Ms. McCaughey is concerned about.

‘‘(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order.

‘‘(5)(A) For purposes of this section, the term ‘order regarding life sustaining treatment’ means, with respect to an individual, an actionable medical order relating to the treatment of that individual that—‘‘(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional’s authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care;‘‘(ii) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;‘‘(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary); and ‘‘(iv) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual.‘‘(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items—‘‘(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems;‘‘(ii) the individual’s desire regarding transfer to a hospital or remaining at the current care setting;‘‘(iii) the use of antibiotics; and‘‘(iv) the use of artificially administered nutrition and hydration.’’.

This apparently is her “list.” In her interview on The Daily Show, Ms. McCaughey seemed very concerned about reference to use of antibiotics and to artificial nutrition and hydration. Apparently she was concerned enough to be distracted from reading that this applies whether the patient wishes full treatment or chooses himself or herself to set some limits on treatment.

She was also apparently unaware of the POLST efforts across the country. Now, to be fair neither apparently is Stewart. However, Ms. McCaughey’s lack of awareness is more troubling, especially since she is held up as an expert on health care. If she had been aware, she would know that these are the categories normative for POLST documents. However, the consultations can only result in POLST documents in states where such documents have been approved, and where they are in programs ‘‘guided by a coalition of stake holders [which] includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors, agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association” – all organizations with an interest in protecting the patient’s rights and wishes.

So, the list of categories that Ms. McCaughey sees as mandated for all advance care planning consultations are in fact categories specific to POLST documents and programs. Moreover such documents are not required in such consultations, and are only possible in states where they are defined and legal, and where a significant number of stake holders are involved, stake holders who from a variety of perspectives have commitments to protecting patients. Certainly, Jon Stewart was unaware of POLST documents, as seen by his repeated reference to life sustaining treatments without reference to POLST programs. However, and again more troubling, it also appears Ms. McCaughey was also unware; and if, as she says, she supports patients’ rights to choose their care at the end of life, she should surely be aware of this movement. With all her credentials, you would think she’d be better informed.

Saturday, August 15, 2009

It’s been a busy week, as much with paperwork as with patients. However, let me point to a couple of items of interest.

First, there is a new web site for the Anglican Health Network. The efforts of the Network are being coordinated by Rev. Paul Holley, Priest-in-charge of La Côte Anglican Church and a member of the Anglican UN group in Geneva. There is a good overview of the Network on the site, as well as news releases. And for those of you who are so connected, you can become a Member of the Anglican Health Network on Facebook.

Second, take a look at 40 Days for Health Reform. This is an effort of a coalition of faith-based groups. You can sign their petition in support of reform. Be sure, too, to check out the Learn More page. It has Guides to the Health Care Debate for both Christians and Jews, and links to denominational positions on access to health care.

You can also participate in 40 Minutes for Health Reform, the National Conference Call on Health Care this Wednesday, August 19, at 5:00 p.m. Eastern/ 4:00 Central/ 3:00 Mountain/ 2:00 Pacific. It's cosponsored by a number of religious communities, including the Episcopal Church. President Obama has agreed to take part, and you can, too. Just follow the instructions on the site to register.

With all the shouting about health care that’s threatening to drown out real discussion, I fear we may miss an important opportunity to do for other what we would have done for us, and to serve Christ in serving the least of his siblings. This is an opportunity particularly for people of faith to support the efforts for reform of our health care and health insurance “system,” while raising some very reasonable concerns.

Saturday, August 08, 2009

So, the two Houses of Congress have gone home for a while without completing a reform of our health care “system.” Well, that’s something of a disappointment, but hardly a surprise.

It’s also an opportunity. After all, this is the time when legislators return home to hear from their constituents, right? So, they meet with individuals and connect with institutions. Some of them also have town hall meetings and other public events.

These public events have also been seen as opportunities by others. They have a clear idea of ways they don’t want the health care “system” to change. They come to these town hall meetings to make their concerns heard. Some of the also come to prevent others’ concerns being heard. Those folks tend to shout more than discuss, to disrupt rather than discuss.

As I said, they have a clear idea of ways they don’t want the health care system to change. They are sadly misinformed in many aspects of their idea. They are misled by some very vocal if unofficial (and hardly unbiased) sources. However, they have, at least for a while, shifted the public discussion from the subject of health care reform to the subject of shouting matches.

Which brings me back to General Convention Resolution C071. I wrote about it before General Convention, and I had the opportunity to speak to it both in its legislative committee and on the floor of the House of Deputies. As I have said a number of times, I think this is perhaps the best resolution calling for universal access to health care that has been passed by General Convention. One reason is the acknowledgement that any health care plan we adopt will have limitations and call for hard choices. The current “system” also has limitations and also calls for hard choices; but those limitations are largely matters of salary and income, and those choices are frequently made for reasons other than patient need and clinical information. We are fooling ourselves if we think otherwise.

But in this time when legislators are home, trying (sometimes trying against a great deal of noise) to hear from their constituents, there is another reason I think this resolution is valuable. That’s because it calls for a response from us. Let me quote the second paragraph:

Resolved, That, The Episcopal Church urge its members to contact elected federal, state and territorial officials encouraging them to:

a) create, with the assistance of experts in related fields, a comprehensive definition of "basic healthcare" to which our nation's citizens have a right,

b) establish a system to provide basic healthcare to all,

c) create an oversight mechanism, separate from the immediate political arena, to audit the delivery of that "basic healthcare,"

d) educate our citizens in the need for limitations on what each person can be expected to receive in the way of medical care under a universal coverage program in order to make the program sustainable financially,

e) educate our citizens in the role of personal responsibility in promoting good health;

Did you catch the important part? Look at the direction: we are to “urge [our] members to contact federal, state, and territorial officials encouraging them to.” Now, the specified content of that contact is important, certainly. Certainly, we want an appropriate common understanding of “basic healthcare,” based on expert opinion and good clinical data; we want it to apply to all citizens (and many of us would like it to apply more broadly); it should be free of political manipulation; and we need education leadership from political leaders and others about what the new system can and can’t provide, and what we can reasonably be expected to provide for ourselves.

But the content isn’t all that useful if we don’t let our political leaders, and especially in this season our members of Congress, know what the Episcopal Church has called for, and that we support the Church in its call. That’s why it’s so important that we contact our officials, and urge those around us to do as well.

So, how do we go about that? After all, the folks that want to stop the discussion are disrupting town hall meetings, causing some legislators to stop having them. There have even been a handful of threats to legislators. So, that doesn’t look like the best avenue.

However, there are others. In 2003 I had the opportunity to participate in “Waging Reconciliation: an Episcopal Response to Healthcare Barriers.” As a part of the meeting, staff members of the Episcopal Church’s Office of Government Relations trained us in the basics of lobbying members of Congress. And they should know how: it’s what we in the Episcopal Church have hired them to do. However, they pointed out that contacts from individual constituents can carry more weight than meetings with professional lobbyists; and the more the merrier.

So, how to go about that? Well, some things have changed. The climactic crisis in the movie “Mr. Smith Goes to Washington” involved bags of letters. Unfortunately, that won’t be as effective any more. Since the attempts to send (real or fake) anthrax spores to congress, letters and packages are screened, and their arrival can be delayed. Instead, the best means are email and phone calls, both to the legislators’ local offices and to offices in Washington.

But, how to get the contact information? Well, in fact most of our phone books have phone numbers of legislators’ local offices. However, there are other places to find all the contact information. I would recommend the web site of the League of Women Voters, an organization with a long history of encouraging voting and educating voters. Moreover, they have a long history of respected as fair and accurate. They used to be the folks who oversaw and organized the debates of Presidential candidates (until, perhaps, the political parties decided they were too fair and accurate). From their web site you can get to their “Elected Officials” page. All you have to do then is put in your zip code, and they’ll give you a list of your elected officials (above the local level), with links to individual pages with their contact information. That includes local and Washington phone numbers, and links to their web pages. So, from there you can write, you can call, or you can email. Alternately, you can use the Web Form on the League of Women Voters site, also linked from the legislator’s page. Those emails will get read, albeit perhaps by a staff member and not the legislator himself or herself. However, they will get read, and you don’t have to try to shout down those who want to dominate the town hall meetings.

Let me say that you can also do much the same thing from the web site of the Office of Government Relations. They will also help you find information about your legislators, and will even send you email bulletins and provide draft emails that you can edit or send as is to multiple legislators. To take advantage of this, you do have to join the Episcopal Public Policy Network. Now, I’m a member and I do think it’s a good network. I do appreciate the bulletins, and while I don’t do so every time, I do frequently send my own emails through their process. However, if you’re not a joiner, the League of Women Voters site is a great resource.

So, here is your opportunity. Be one of the first to actually carry out a resolution of General Convention. It will bring more measured and informed voices to our legislators when we need them most, and without having to fight our ways through the shouts of those who are themselves misled, and may mean to mislead others. It’s not that hard, but it is certainly another means to love neighbor as self, not only in individual encounters but in shaping our civil society.

Wednesday, August 05, 2009

So, I’ve described my experience of the General Convention as a marathon. If my description didn’t make you tired, you’ve got more energy and endurance than I have. If I’ve inspired you to pursue this yourself, some will think you strange – but I won’t.

I have a conviction that I need to leave things better than I found them. That applies to the Church as much as anything else.

Now, I will admit that I have a moderately high opinion of my own work. I’m pretty good at the bedside after all these years. And one of the things I say about my work is that, where my parish colleagues will speak of being in Sales, I say I’m in Maintenance. Part of the reason I say that is that I’ve encountered my share of folks suspicious of me because of how they’ve experienced other religious professionals. I like to think I’ve given them a different experience, one that can repair their relationship, if not with God at least with other believers.

But I’m also aware that I can only encounter so many folks. However much of my time I might spend at the bedside, there are only so many hours and so many patients. On the other hand, if I shape the environment for better spiritual care, I benefit many more people than I can actually meet. So, while it isn’t my first love, I’ve learned the value of program and policy development. I sometimes joke that I do my best to convince my hospital that I’m indispensable; the fact is that I know better. On the other hand, I make the most of my opportunities to participate in leadership and program planning. It helps me step beyond individual patient care to provide for our patients what I speak of as “a spiritually safe place.”

I’ve done that in other settings as well. That has been my purpose in leadership in professional organizations. It was even the reason (well, part of it at least) that for a while I explored whether I have a vocation to be a CPE Supervisor.

For me, participating in the General Convention is perhaps the largest setting within which to pursue the same goal. Serving as a Deputy is an opportunity to help shape the culture of the Church. In a way I’m much less of a player than I am, say, in my hospital. At the same time I do love the Episcopal Church, and I have my own sense of how the Spirit is calling me and calling the Church. So, it’s as important to be a small fish in the big pond of General Convention as it is to be a big fish in the small pond of my hospital.

I will admit, too, that I’ve felt some of the same satisfaction in participating as an Exhibitor. The opportunity to share a ministry with so many Episcopalians and to expand the various networks for ministry that I participate in can, I believe, also participate in shaping ministries within the Church, if not the Church as a whole.

I will also admit I take a personal pleasure in all that networking. I’m a social guy. I like to connect with folks. I have friends that I only see at General Convention. I have friends from years gone by that I see and can reconnect with at General Convention. And then, of course, there’s the fun of making new friends. I do consider General Convention something of a party, even a family gathering. I used to call it (with apologies to “Guys and Dolls”) “the oldest established permanent floating cocktail party in Christendom.” I haven’t backed off of that because I mentioned it in a sermon and was chastened for it by a retired bishop in the congregation. Actually, I’ve backed off of it because people are exercising a bit more discretion. Still, it’s a fun time.

However, the important point for me is, I think, the important point for many of us: to help make things better than I found them, including the Church. I know that there are folks that disagree with me about where the Spirit is leading the Church. At the same time, they also see as important this effort to participate in leadership. That’s why I want them there, why I was glad to have in Anaheim those who disagreed with me.

So, there is it: for all the work and sleep loss I experienced in Anaheim, this is why I thought it important to play a part. Will I do it again? Well, I’ll have to get elected to serve as a deputy first, and that’s more than a year away. But will I do my best to be there? Absolutely. I think every Episcopalian should see it. If it’s not a cocktail party per se, it’s still the oldest established permanent floating family gathering in the American church scene. I think everyone ought to come. And when they come, they can take some part, significant if however small, in shaping the future of the Church, and leaving it better than they found it.